Period products, health risks, and regulations

Period poverty is the circumstance of lacking supplies and facilities to manage menstruation comfortably, safely, and without shame. As a researcher who studies period poverty and its effects on adolescent girls’ school attendance and engagement, I am concerned about the growing body of research documenting the exposure to chemical toxins and heavy metals that accompanies use of commercially produced menstrual hygiene supplies (e.g., tampons and pads). The most recent study documents the presence of 16 heavy metals (including arsenic, mercury, and lead) among 14 tampon brands. Though none of the tampons evaluated contained measurable amounts of all 16 heavy metals, all brands contained some heavy metals. Heavy metal exposure is associated with adverse health outcomes, including impairment of the nervous system, organ damage, and increased cancer risk. A 2019 study found that sanitary pads contain volatile organic compounds (VOCs) and phthalates, both of which are associated with menstrual irregularities and cancer.  

The finding of heavy metals in tampons and harmful chemicals in pads, coupled with the fact that the Food and Drug Administration’s (FDA) regulation of these products does not mandate regular testing for toxic chemicals, turned my concern into alarm. Sanitary pads became commercially available in 1921, and tampons followed 10 years later in 1931. This cursory monitoring over the 100-plus years of period products’ commercial existence is consistent with the idea that, as “medical devices” (period products’ classification given by the FDA), the treatment offered is concealment—hiding menstruation from everyone but the person experiencing it. Given this focus on keeping menstruating bodies a secret, it is not surprising that regulation did not extend to studying how products designed to keep that secret affected menstruating bodies.  

These findings demand that we expand our efforts beyond concealment—that assessment for health risks to users be a routine aspect of menstrual hygiene product manufacturing. They remind us that medical interventions are enacted upon dynamic organisms operating within complex systems. Neglecting that dynamism and complexity to devise a singular solution can have unintended consequences.  

In the current case, the “interventions” are menstrual hygiene products. Menstruation involves not only the vagina (the channel for menstrual blood flow), but the circulatory system, which functions to both nourish organs and absorb native and foreign substances within organ tissue. The unintended consequence is the possibility that these products, in addition to absorbing menstrual blood, introduce an as yet undetermined quantity of heavy metals and potentially harmful chemicals into the bodies of menstruating people. The implications of these findings are that we can no longer afford the simplistic view of menstrual hygiene products as an exercise in concealment. Rather, we must consider product use as a potential entry point for physiologic risk and take appropriate steps to monitor and safeguard the health of the menstruating public.  

At the same time, it is important not to leap from “VOCs, phthalates, and heavy metals are present in menstrual hygiene products” to “menstrual hygiene products are toxic,” however logical this conclusion may appear on its face. There are important questions that the studies of menstrual product contents do not answer. These include:  

• What is the level of heavy metal/toxic chemical exposure through period products through food or water?  

• What amount of toxic chemicals and/or heavy metals are absorbed from period products placed against the vulva or inside the vagina over the course of an average menstrual period? Over the course of a reproductive life?  

• What is the strength of the association between toxic chemicals and heavy metals in period products and health risks? What, specifically, are the health risks?  

Devising a reasonable, evidence-based course of action to mitigate individual risk of toxic exposure from period products requires answers to these questions. Discontinuing use of commercial period products until research provides answers to these questions is not feasible. In the meantime, sharing what information exists with the public, including suggestions for reasonable action steps, has already begun. In an early July interview with NPR, Dr. Nathaniel DeNicola, an OB-GYN with expertise in environmental health, recommended paying attention to the ingredients listed on tampons’ product labels and considering period management alternatives, like reusable menstrual cups. 

Policy-level action must accompany research on the health effects of toxin exposure via tampons and pads. More rigorous federal regulation of menstrual products manufacturing is imperative. Requiring manufacturers to routinely monitor period products’ chemical contents will provide the data needed to assess health risks and will facilitate the creation and enforcement of appropriate product safety standards. 

Strengthening the regulation of menstrual hygiene products’ heavy metal and toxic chemical content also serves health equity. The risk of excess toxic chemical exposure is not equally distributed across populations. The environmental justice literature is replete with examples of disproportionate exposure to toxins in poor communities, rural communities, and minority communities. Because ambient exposure to toxins is likely to be greater in these communities, there is a greater likelihood that the presence of toxins in menstrual hygiene products will constitute meaningful excess risk among members of these communities.

Because the communities that are more likely to experience toxin exposure through their living environments are also less likely to have access to a wide range of period products, a non-regulatory, market-based response would likely not change the potential risk of toxin exposure in these communities. The current range of commercially available period management products is, in part, a response to ongoing concerns about product content. “Product choice” is the result—options from “cheaper value” products to “premium” products marketed as “more natural” or “safer” and carrying a higher price point but which are no less likely to contain heavy metals. Stores in lower-resource communities may be less likely to stock a full range of menstrual hygiene management options because of low demand for premium products, which are likely less affordable for the residents of these communities.  

The response to concerns about the chemical content of period products that focuses on increasing product choice may, in turn, worsen period poverty and menstruation-related school absences in poor, minority, and rural communities. If the options for period management narrow to resigning oneself to toxin exposure, paying for a more expensive product, or staying at home and using fewer products, some school-aged girls may miss school at least some of the time. Given the association between educational attainment and long-term health outcomes, such a choice does not bode well for future health at either the individual or the community level. Regulation of period management products that includes systematic evaluation of menstrual products’ materials and those materials’ health effects, examination of patterns of use by menstruating persons, and monitoring local levels of toxin exposure will ensure that the benefits of those assessments and any changes made for the purpose of product safety will accrue to all people who use these products.